Group Processing and Client Centered Approach Joy Baldwin Manager Interim Federal Health Medical Services Branch Citizenship and Immigration Canada Vancouver, February 23,2007

The Karen Movement 2006 Enhanced client-centered approach to group processing for protracted groups of refugees coming from high risk environments

Saskatoon, August 18, 2006 Amongst the first Karen refugees welcomed to Canada

Rationale for an enhanced immigration health management International trend : Other major immigration receiving countries such as U.S. and Australia are enhancing their immigration medical screening for high- risk populations. Epidemiological evidence: Certain populations are at higher risk of developing conditions of public health concern. CIC resettlement process: refugee group processing Large movements of people over a short period of time All coming from high health risk environment Significant number of individuals to resettle in limited number of cities Better integration of high risk populations for mutual benefits of Canadians and immigrants

Overview of a high risk population: the Karen Refugees Canada has agreed to resettle 810 Karen Refugees in All lived in a crowded, remote camp in northern Thailand for over a decade. Described as “the poorest of the poor”. Very limited health services available in the camp. Vaccination status not known. Frequent outbreaks of malaria, dengue hemorrhagic fever, cholera, influenza-like illness over the past few years. High Tuberculosis (TB) and MDR-TB incidence/prevalence amongst refugees in Thailand.

Tuberculosis statistics amongst refugees in Thailand TB prevalence in Thailand refugee camps over the past two years: 2,674/100,000 MDR-TB: 76/100,000 for the Burmese refugees - 10% of all positive cultures; 126/100,000 for the Hmong refugees - 30% of all positive cultures. Active TB diagnosed amongst the 805 Karen refugees coming in Canada: 9 ? cases/805 refugees: 621/100,000

Enhanced Immigration Health Management To ensure optimal immigration medical screening of high risk populations For the protection of public health of Canadians For the benefits of individuals at high risk Interventions to happen Pre-departure Post-arrival Limitations and challenges Demographic constraints Time constraints Technical constraints Communication challenges.

Enhanced immigration health management of Karen Refugees Pre-departure and post-arrival initiatives Enhanced TB management: Shorter validity date of the immigration medical examination (IME) All children ≤ 10 years referred to Public Health (PH) authority All cases of Pulmonary TB-inactive (PTI) referred to PH authority for an urgent assessment Fitness to fly assessment within 72 hours pre-departure Strengthened communication with provincial health authorities and timely sharing of information Enhanced coordinator role for CIC Comprehensive medical examination covered by the Interim Federal Health (IFH) program

Implementation and coordination Establish contact with high level Public Health officials in each province Establish communication network of local CIC, Public Health and SPO reception center personnel Establish and maintain contact with IOM personnel conducting Fit to Fly assessments Prepare/distribute PHAC recommendations to public health PHAC recommendations to primary care physicians Interim Federal Health billing instructions Letters to clients

Implementation and coordination Prepare sealed medical files on each client and with instructions to primary care physicians to be sent to local CIC offices and distributed to each client prior to their comprehensive medical examination Provide local Public Health with lists of children prior to their arrival Copy and send files and films on all PTI cases to local Public Health as soon as destination is confirmed Ensure post evaluation information is collected from local CIC, Public Health and primary care practitioners where possible

Enhanced immigration health management: success Timely support and advice by stakeholders (such as the Public Health Agency of Canada (PHAC) and the Canadian Tuberculosis Committee (CTC)) Great opportunity to strengthen our network with partners: Within the PHAC CCMOH Provincial and municipal public health authorities Internationally (US/CDC, IOM) Close collaboration amongst CIC Branches involved in the Karen refugee resettlement process Timely sharing of information, facilitating the health assessment by PH authorities More efficient interface with primary care for high risk population

Enhanced immigration health management of Karen Refugees: challenges The need to refine criteria defining non fitness to fly Process challenged by a recent outbreak of acute hemorrhagic conjunctivitis Operational challenges due to the fitness to fly assessment location Facilitation of the process if done within the refugee camp Late involvement/awareness of Medical Services Branch, CIC in the Karen Refugee resettlement process MSB to work in early and close collaboration with other CIC Branches for future refugee group processing Communication challenges Wide audience: international, national, provincial, municipal and non- governmental organizations Need to develop network of contacts at multiple levels Timely communications with all stakeholders

Evaluation of the enhanced immigration health management of Karen Refugees Is there any benefit to continuing the enhanced immigration health management for high risk populations? What is the impact on public health? Tuberculosis Immunization What are the benefits of doing a comprehensive medical examination soon after arrival? What is the impact of this enhanced approach on integration and access to care of high risk populations newly arrived in Canada?

Evaluation of the enhanced immigration health management of Karen Refugees (cont’d) Standardized tools amongst provinces receiving refugees: Karen Refugee - TB control form Karen Refugee - Comprehensive Medical Assessment form CIC analysis of the IFH database for the Karen refugee group Key elements of success: Participation of provincial/municipal public health authorities Participation of involved health care providers Successful integration into the Canadian health care system and optimal health outcomes for clients

Next steps Analyse the impact/benefits of the enhanced immigration health management of high risk populations Review and refine the medical content of the protocol Pre-departure initiatives Post-arrival initiatives Develop criteria defining high risk populations Not limited to refugees

Welcome to Canada – Saskatoon, August 18, 2006 an integrated client-centered success story